Expensive Medical Tests – Who Really Wins?

Here’s one of the best examples I’ve encountered of the dysfunction of American medicine. It will leave you shaking your head. And you might be surprised by my comments about it. Here’s the scenario as described in the Syracuse Post Standardthis week:

Recently, Excellus Blue Cross Blue Shield, the largest health insurer in Central and Western New York State, invoked a policy wherein physicians who order MRIs, CT scans, PET scans and other expensive diagnostic tests are required to get permission to perform those tests, or the test won’t be reimbursed — meaning — if the patient has the test, the patient must pay out of her pocket– her insurance won’t cover it. They say they have done this because the number of MRIs have gone up 100 percent in three years and they need to stem the tide of these expensive tests.

A high school girl injured herself, and her orthopedic doctor, Irving Raphael (who also happens to be team physician for Syracuse University), ordered an MRI to look at what he was sure was a stress fracture. But when he tried to get permission from Excellus, he was turned down and told he had to prove the girl had a stress fracture (so he could give her an MRI to prove she had a stress fracture. Seriously.)

So — since he did not get permission to give her the MRI, (and presumably because her parents didn’t want to pay for one themselves, because they are quite expensive – up to $1000) the doctor simply sent the girl home, and told her to stay out of gym class.

I’ve chatted with a number of folks about this, including my editor at the Post Standard. Most are outraged. It makes them mad that something that has become routine in most places is now under scrutiny, and they place the blame squarely on the shoulders of Excellus’ greed — like — what else is new?

So let’s break this down by participant:

From the doctor’s point of view: he feels like he can’t do his job without the right tools. His practice owns some of those tools, although whether he owns the MRI is unclear in the story. That’s really no different from the carpenter who owns his own hammer, or the plumber who owns his own snake, is it? Except that payments for an MRI lease are likely huge (5 figures per month is a guess) — and the more MRIs he does, the more money he makes.

But more important for the doctor is the fact that it’s HIS job to help this girl heal. If he can’t properly diagnose her, he feels as if he can’t properly treat her. Not only does he have the ethical obligation to do so, but he runs the risk of malpractice if he doesn’t.

Now –I’m not a doctor — but I went online to see how a stress fracture is diagnosed and treated. Turns out an x-ray, the “old fashioned” approach to a stress fracture, can rule out anything more damaging than that stress fracture. It does require an MRI to see the stress fracture.

Bottom line? Regardless of how the stress fracture is diagnosed, the treatment is the same, regardless of whether Dr. Raphael does an MRI on it or not. And regardless of whether he charges Excellus $1000 or not.

From the patient’s point of view: She has a stress fracture. She must stay off her injury for six weeks. No matter how she is diagnosed, her circumstance doesn’t change.

From Excellus’s point of view: You know, I rarely have anything positive whatsoever to say about health insurance companies. Their only goal is to take as much money as they can from patients, and pay out as little as they can, and patients die everyday from denied benefits, or too little assistance. It’s a profit model which, while I do understand it, I think has gotten out of hand.

In this circumstance, they identified a major hole in their rules – and wanted to plug the money gush. They are convinced that doctors are ordering tests that are excessive and unneeded. So they set up a new policy requiring permission — which means — they aren’t denying all the MRIs, CTs, etc — just the ones they think aren’t needed.

The question is — who says they aren’t needed? You’ve got a doctor who is trained to do this work, asking a nurse for permission. Does that make sense?

From the consumer’s point of view: This is where I differ from my usual point of view. In this case, I actually support Excellus looking at ways to cut their costs for the expensive tests. The care for this girl didn’t change at all, regardless of the fact that she had no MRI. There are thousands of these unneeded MRIs and other tests being done on a regular basis — and do you know who is paying for them? We are. As consumers of health insurance, all those extras are being subsidized from MY premiums and YOURs.

The bigger problem here is that Excellus really did it wrong. You can read the article to see how they went about putting their policy into place — wrong wrong wrong — and just plain dumb. It wasn’t until after the new policy imploded on them until they went back to correct it. But the damage in the form of distrust, and patients lost to the new policy, can’t be undone.

As patients, we want the best treatment. But we can’t continue to equate the most expensive and extensive tests to the best treatment. Granted, having those capabilities is important — and I want to know they are available — but they just aren’t necessary for every instance. Using them is like taking a limosine to the supermarket…. it might be nice, but it just isn’t necessary! There are even some who believe that some of the tests, used too often, can be dangerous for the patient due to exposure to radiation.

As consumers, we want the lowest cost for the best treatment. Insisting on expensive, yet unnecessary tests, continues to cost us more and more. We need to begin asking questions of our doctors about these kinds of tests, looking them up to learn more about them, and managing parts of our healthcare with the intent of keeping our wallets as healthy as our bodies.

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2 comments

Stress fracture or not…this story illustrates the (sometimes) arbitrary hoops and obstacles which insurance companies place between the doctor and the patient. I have a friend who was air force at the time he thought that he may have experienced a stress fracture in his foot/ankle and was trying to take it easy. His civilian boss was concerned and sent him to the base hospital where he was later diagnosed with bone cancer. Sometimes tests, expensive or otherwise, are necessary in determining the best treatment for the patient.

It’s very hard to do anything equitably under a system of covert rationing. Why shouldn’t a young athlete have access to a scan that would possibly allow her to return to competition, when other young athletes all over the US have access? But on the other hand, why should we be paying as a society for such scans when others (many of them taxpayers, contributing to Medicare) don’t have coverage for anything?

Open rationing would give a more equitable solution. My guess is that under an equitable system that included open healthcare rationing, diagnosing stress fractures would be done the way it was done back when I was a young runner – by clinical judgment. This young runner would be sitting (or suffering) whatever test was done.

If, after conservative treatment, the problem persisted, then more expensive testing could be done to look for the extremely low-probability explanations like the one Ms. Emrich describes. Under one system, some patients get immediate high-tech low-yield tests to the great cost of society (one of which is that 47 million people are priced out from ANY routine testing); under the other the rare patient has a 4 – 6 week lag in the diagnosis of a more serious problem. Which scenario is more equitable? That’s what we’re deciding now.